IPs Respond to CMS Legionella Directive

Almost a year has passed since the Centers for Medicare & Medicaid Services (CMS) issued a compliance memorandum telling healthcare systems to perform risk assessments and implement water safety programs to prevent patients from acquiring Legionnaires’ disease (LD).

It’s making a difference in terms of infection preventionists putting Legionella on their radar and hospitals seeking testing and risk assessment advice, says Janet Stout, PhD, president of the Special Pathogens Laboratory in Pittsburgh.

She predicted as much last year after the CMS memo was issued right before the annual APIC conference, turning Stout’s relatively pedestrian Legionella presentation into “must-see” IC.

Facing a packed crowd seeking compliance guidance, Stout finally was no longer a voice in the wilderness.

After investigating LD since that first, titular outbreak in 1976 at a Legionnaires’ convention in Philadelphia, Stout was ready to share a wealth of accumulated information.

“When I speak at something like that — there are also other sessions going on — I expect something like 50 or 100 people,” she says. “It was standing room only. There must have been 500 to 600 people there. That was a dramatic visual depiction of the impact of the CMS memorandum. When CMS speaks, every healthcare facility listens.”

The CMS outlined the situation in no uncertain terms. The compliance directive was needed because a review of the increasing number of LD outbreaks in 2000-2014 showed that 15% were in hospitals and 19% in long-term care.

“The CMS expects Medicare-certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems,” the agency emphasized.1

Primarily caused by Legionella pneumophila serogroup 1, LD outbreaks in healthcare are typically traced to the waterborne bug becoming aerosolized and inhaled in shower mist. Faucets, spas and baths, cooling towers, decorative fountains, and medical equipment also have been implicated.

Hospital Infection Control & Prevention asked Stout to update the situation in the following interview.

There is no reason to be afraid to evaluate the presence of Legionella. What gets people stuck is that they believe for some reason that you can completely eliminate a naturally occurring bacteria from complex water systems in hospitals and long-term care facilities.

You can’t. You can control it, which is sufficient to manage or prevent disease. That is the “zero” worth looking for. We are looking for zero cases of LD, not zero bacteria.

HIC: While there often is resistance to regulation in clinical settings, you have made the case that this CMS action is a good thing.

Stout: When the memorandum came out last year, I emailed the contact person and said, “Congratulations on doing something that will dramatically move the prevention of healthcare-acquired LD forward — forward in a way that will be much more substantive than the ASHRAE standard that came out in 2015, or even the CDC water management toolkit.

First of all, the CMS memo was short and to the point. You must have a risk assessment and water management plan to address the risk of Legionella in your facility, and you need to have measures that demonstrate control, including testing for pathogens like Legionella.

HIC: Legionella has come to national attention following outbreaks, but subsequently fades back again. Will this regulatory aspect finally set prevention as a priority?

Stout: The only caveat I will say is that it has the potential to dramatically reduce healthcare-acquired LD. In the Special Pathogens Lab, we do the testing for Legionella and other organisms, and do consultations to help people comply with CMS and other standards.

We have seen a dramatic uptick in requests for testing, risk assessments, and water management plans. Usually with these things there are early adopters, people in the middle, and later adopters. With ASHRAE, even though it was an industry best practice, it was still a voluntary standard. CMS is not voluntary.